1: Introduction

Kristaps J. Keggi

This introduction is a collection of personal recollections of total hip surgery, the anterior approach, and some general thoughts.

It was 1970 and the beginning of the “total hip era,” which was launched by Sir John Charnley. I had finished the Yale University School of Medicine and its orthopedic residency in New Haven, 11 and 6 years earlier, respectively. I had been on active military duty for 2 years, the first of these on the teaching staff of Beaumont General Hospital in El Paso, TX, and the second with the 3rd Mobile Army Surgical Hospital in the combat zones of Vietnam. I had returned to Yale and Connecticut in 1966 to teach and practice orthopedic surgery in Waterbury and New Haven. It was the beginning of a career with Yale University faculty appointments that began with a title of “instructor” and ultimately allowed my growth to an endowed professor at the university (Figures 1.1-1.3).

Figure 1.1

1960-1970—the beginning of a New Era with the cemented, low-friction, hip arthroplasty developed in England by Sir John Charnley.

Figure 1.2

A young John Charnley evolved as an orthopedic surgeon during his military service in the WWII “School for Surgeons.”

(Reprinted with permission from

Somford MP, Hoornenborg D, Wiegerinck JI, et al. Eponymous hip joint approaches. Arch Orthop Trauma Surg. 2016;136:1007-1014. doi:10.1007/s00402-016-2456-2.)

Figure 1.3

Radiograph of the Charnley low-friction, cemented implant showing the transected and reattached greater trochanter used to perform his hip operations in civilian life.

Sir John Charnley (1911-1982) evolved as an orthopedic surgeon while serving with the British Royal Army Medical Corps during World War II (see Figure 1.2). After returning to civilian practice, he continued both clinical and research work, which led to the introduction of his low-friction, cemented total hip arthroplasty, with rapid success, to the worldwide orthopedic community in the early 1960s.

My career was developed with the help of my father, a dedicated surgeon; my maternal grandfather, a theologian and educator; the rest of my family; Yale; the “old” Roosevelt Hospital in New York; orthopedic training with Dr. Wayne Southwick in New Haven; the Army with a year of war surgery in Vietnam; and the academic support of my work at Yale and Waterbury Hospital by Dr. Gary Friedlaender, the long-standing chair of Yale Orthopaedics and Rehabilitation. The Yale Cushing/Whitney Medical Library and the history I learned there have also been a major part of my thoughts of the past and the future. I think of the past and such giants of surgical history as Andreas Vesalius, Ambroise Paré, Hieronymus Brunschwig, John Hunter, Baron Larrey, William Halsted (Yale College, graduated in 1874), and Harvey Cushing (Yale College, graduated in 1891), as well as the future as I look at the great contributors to this second edition of The Direct Anterior Approach to Hip Reconstruction (Figures 1.4 and 1.5).

Figure 1.4

Wayne O. Southwick, Professor and Chair of Orthopaedic Surgery and Rehabilitation at Yale University during the beginning of this New Era. A great teacher, superb surgeon, innovator of new procedures and sculptor outside of the operating room. Surgeon with the United State Marines in the Korea War “School for Surgeons.”

(Reprinted with permission from the Department of Orthopaedics and Rehabilitation at Yale University.)

Figure 1.5

Kristaps J. Keggi as a young, orthopedic surgeon with the 3rd Surgical Hospital, Army, Mobile “MASH” during his time in Vietnam War “School for Surgeons.”

Dr. Wayne O. Southwick, surgeon, sculptor, and teacher arrived at Yale in 1958. I was one of his first students, and it is he who inspired me to become an orthopedic surgeon. He had also served as a surgeon in the Korean War and had made a point of teaching us the basics of war surgery, which served me well in the care of my wounded patients in the combat zones of Vietnam. I feel privileged to have served and even more privileged to have learned lessons that have served me well with conventional procedures and new ideas such as the direct anterior approach (DAA).

As the senior citizen of this book’s editors, I do have to record some of my recollections of the early years of the total hip era and the evolution of the DAA. I hope they will be of interest, or amusement, to its current readers and those who may be looking at it in the future.

With Dr. Southwick’s encouragement, during the course of my Yale orthopedic residency and my early years of practice, I had used and tried (at least “seen one, done one, taught one”) every conceivable approach to perform hip procedures, including fusions, excision arthroplasties, osteotomies, fascial arthroplasties, femoral head replacements, tumor operations, treatment of infections, fixations of fractures, denervations, tenotomies, and debridement of gunshot wounds.

The third edition of Campbell’s Operative Orthopaedics, which was published in 1956 and I still have, had been our “bible” and guide for these various approaches and procedures. Sixty years later, as I look at this book again, I continue to be impressed at how well operations and surgical approaches were described and how each was given the name of its proponent (ie, lateral approaches to the hip: Ollier, Gibson, Mcfarland, Callahan, Osborne, Fahey, and Watson-Jones; from the back: Osborne, Ober, Moore, and Guleke-Stookey; from the front: Barden-Heuer, Sprengel, Larghi, Hueter-Schede, Cubbins, Rowe, Sutherland, Smith-Petersen, Judet, Luck, and Thompson; and from the medial, proximal thigh: Ludloff). I remember them, so as we think about our DAA today, these old names and surgeons must be given the recognition they deserve in the history of hip reconstruction and surgeon education.

The medial Ludloff approach (1908) still intrigues me. I had used it to reposition a congenital hip dislocation and years later considered it as a potential total hip approach. It is a recollection and a thought, but it may deserve consideration by future surgeons thinking of something new—just like so many other procedures first described in the German literature more than 100 years ago (Figures 1.6-1.11).